Provider Demographics
NPI:1366830457
Name:GUDIC, MIRSADA (DPT)
Entity Type:Individual
Prefix:
First Name:MIRSADA
Middle Name:
Last Name:GUDIC
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 LYNGATE CT STE 203
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1673
Mailing Address - Country:US
Mailing Address - Phone:703-239-2300
Mailing Address - Fax:
Practice Address - Street 1:650 PENNSYLVANIA AVE SE STE 170
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003
Practice Address - Country:US
Practice Address - Phone:202-544-4874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-26
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT024208225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist